We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Credentialing Department provides Credentialing services for practitioners affiliated with Prospect Medical. The Sr. Credentialing Coordinator position performs credentialing and re-credentialing activities according to Prospect Medical Credentialing policies, contracted health plan policies, CMS, state law, and NCQA accreditation guidelines. This position acts as a liaison between our IPAs and contracted health plans to perform any credentialing needs as needed.

Job Responsibilities/Duties

• Review practitioner and organizational provider credentialing and re-credentialing applications for completeness.
• Review and analyze credentialing documents, including education, residency and fellowship training, board certification and eligibility, licensure, professional work history, liability insurance, requests for clinical privileges, malpractice history, and accreditation.
• Assess completeness of information and provider’s qualifications relative to established standards.
• Determine appropriate verification and reference letters to be prepared for adequate processing of each individual application and reapplication.
• Identify and flag adverse information from provider application materials for the purpose of conducting follow-up investigations.
• Request facility site reviews from appropriate sources (i.e. CalOptima) on applicable providers.
• Responsible for completion of re-credentialing files within a 36-month timeframe.
• Update new information as received via re-credentialing process.
• Maintain and exceed quantity and quality goals and standards set by the department.
• Lead role in ensuring that Ongoing Monitoring Reports are reviewed within a 30-day cycle as required and that all required steps are taken and attested to by monitored providers.
• Lead role in responding to all health plan ongoing monitoring inquiries in a timely manner.
• Perform self-audits on all files processed prior to QA review.
• Prepare summary packets for Credentialing Committee review on all files not meeting the Clean File Criteria.
• Semi-annual and quarterly reports.
• Additional Responsibilities for Credentialing Coordinator as assigned including assisting with Committees and reporting.
• Obtain and verify expired documents including licensure, board certification, and liability insurance.
• Support training of new staff members.
• Utilize system reporting to identify areas for improvement and work with the Credentialing Manager and Trainer to establish new/updated policies and procedures.
• Lead credentialing projects to ensure timeliness of application processing, system data integrity, and compliance with all required standards, policies, and laws.
• Demonstrate and maintain credentialing knowledge. Keep abreast of new and changing regulations and standards.
• Follow and abide by departments Policies and Procedures
• Other duties as assigned.

Qualifications

Minimum Education: High school diploma or equivalent.

Minimum Experience: 2-5 years of experience in credentialing. Requires a dynamic person with the ability to work in a fast-paced environment. Excellent written/verbal and organization skills required. Must be proficient in Excel and Word skills. Preferred proficiency in Adobe Acrobat Professional. Must be highly organized with excellent attention to detail and clerical accuracy. Must be self-motivated with the ability to complete projects independently within established timeframes. Previous credentialing experience with IPA/Medical Group utilizing NCQA standards preferred.

Req. Certification/Licensure: NONE.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www.eeoc.gov/